7
Sorting It Out: Getting Help
Some nurses knew that they wanted to see someone in behavioral health as soon as they returned. Others decided to wait and see how their lives unfolded before making an appointment. Although they recognized the value of mental health therapy, they were concerned about the “stigma” and the possibility of interference with future assignments and promotions.
Stigma refers to a set of negative or unfair beliefs that a group of people have about something. It reflects dishonor, shame, and disgrace. In this chapter, we are talking about the “stigma of a mental disorder,” which can lead to humiliation and discrimination. One harmful effect of stigma can be the reluctance to seek treatment for mental health problems. The fear of adverse career consequences can act as a barrier to a service member seeking treatment for posttraumatic stress disorder (PTSD) and similar illnesses. When available mental health services are not utilized, service members put themselves at risk for negative outcomes, including suicide.
Most of the nurses who sought mental health counseling said that they found it helpful. Some did couples therapy and others did individual therapy. Some sought suggestions to help their children. Many dealt with compassion fatigue and various degrees of PTSD. A few nurses mentioned that they went to civilian mental health care providers to avoid have things written in their military medical records. They feared breaches of confidentiality and invasions of their privacy. Some felt that stigma was still alive and well in the military. They did not want to risk future promotions and assignments.
LIEUTENANT COMMANDER KATHLEEN
Kathleen, a navy nurse, stated:
When I came home I had trouble sleeping. I was quick to anger. I knew I needed to talk with someone but put it off because I was afraid it would affect my career. I just didn’t want to put everything I had worked so hard for in jeopardy. It was very difficult because I don’t care what anybody says, but there is still a stigma attached if you go to the mental health clinic. If you are an active duty service member, you are taking a big chance going for mental health services. They say it won’t affect your future, but I just didn’t buy that. I went to another town about 20 miles from my base to see a civilian counselor. She kept everything confidential and she was helpful to talk with. She helped me sort out my issues. She told me I had “clinical burnout” and some PTSD.
CAPTAIN EARL
Earl was a paramedic and registered nurse, who joined the Air Force Reserve a few years after graduating from college. He was raised in the Pacific Northwest and still resides there. He and his wife both had deployed to Iraq as flight nurses, although they were prohibited by regulations from flying on the same aircraft.
Earl reported:
My wife and I were both flight nurses. We came home within a week of each other. At the time, she was fine, and I was not. I had anxiety and anger issues. It seemed like anything I enjoyed before, I didn’t enjoy anymore. Finally, my wife said, “Your behavior is way out of line. You need some kind of help.”
Here’s my story. I was recalled to active duty during the initial invasion of Iraq in March 2003. I was part of the first squadron for aeromedical evacuation to fly the wounded out of Iraq and Afghanistan back to Germany to Landstuhl Hospital. We had to build the squadron up from scratch. There was no system in place. There were no theatre hospitals in Iraq and Afghanistan so all the casualties were flown back to Landstuhl, until they could get a theatre hospital set up in Balad and Bagram. It was very difficult because we were a small squadron, and we only planned on the war being 6 weeks long. Our workload actually increased. It was a very difficult environment because on some days we didn’t have enough crews to stand alert to fly urgent missions. We got beat down pretty bad. I was on the flight schedule for 115 days and evacuated 800 casualties on 56 different sorties. Our biggest patient load was 78 patients split between three nurses and four medics. It was very difficult, and then they didn’t have ground support. So, days when you were not flying, you’d be out on the flight line loading and unloading planes. There could be three or four planes a day. So, about 6 months later they replaced my unit because they knew we were all getting burned out. And in the 6-month period, we had evacuated over 7,000 casualties from Iraq and Afghanistan to Germany and then another 3,000 back to the States. Literally, that squadron of 150 people experienced a tremendous number of casualties in a 6-month period.
Earl talked about returning home:
When we got home, no one really asked us how we were doing. I think they assumed we were nurses and that is what we do. People thought your special training immunized you or made you exempt from combat trauma. The term “compassion fatigue” did not really exist back then, and PTSD was not really discussed. I recognized that my crew was having some problems, and I was having trouble with sleep. I went to the flight surgeon about my sleeping problems, and he grounded me for 3 months diagnosed me with “combat fatigue.” There really wasn’t a process. My wife was also deployed in two different countries. She was in Oman and then in Pakistan. She came home after 6 weeks and was fine. She was still the same person.
My reintegration was a problem, and we were both flight nurses. She was fine, and I was not. I started thinking that something was wrong with me because we basically did the same thing. I had anxiety and anger issues. I couldn’t even put on a life jacket for water skiing, which is something I always liked to do without experiencing anxiety. It seemed like anything I enjoyed before, I didn’t enjoy anymore. And finally, my wife said, “Your behavior is way out of line. You need to go and see the flight surgeon. You need some kind of help.” We were having all kinds of fights. The air force was not doing anything to help. They gave us 2 weeks off, and they said, “You better start preparing to redeploy. And you’ll be going for 6 to 9 months.” Well, the last thing I wanted to do was to get back on a plane. So, that created additional anxiety for a lot of us because the war wasn’t over, and they were telling us that we’d probably have to redeploy.
I was mobilized in January 2003, deployed in March 2003, and came home in August 2003. The air force jumps back and forth between 4- and 6-month deployments. They never do a year. It seemed like every week the air force had a different plan for us. Nobody was accepting that this was gonna be a long-term war. They kept coming up with these short-term fixes. There was such a lack of planning.
LIEUTENANT KATE
Kate, a navy nurse who served in Afghanistan, reported:
I tried once to go for counseling. It took me a while to realize that I was having difficulty dealing with people when I got home, and even with patients once I was home. I was having a real hard time with people and relationships. I only went for counseling once, and since it didn’t seem to help, I quit going right away. Even though they say there is no stigma in going for counseling, I think there still is. I was uncomfortable with getting help from naval mental health services because I was also a health care provider. When I went for my counseling session, I was guarded in what I said because I didn’t want stuff going in my medical record. I didn’t want my medical colleagues to have access to my health record pertaining to mental health and coping issues. So, my husband and I decided to try to iron things out on our own.
LIEUTENANT COLONEL TONI
Toni, an Air Force Reserve Critical Care Air Transport Team (CCATT) nurse, described her family situation:
I’m married, and we have five children. Most of them were teenagers when I deployed. We are very blessed that they are all good kids. The youngest is now 19. My husband and I ended up going for counseling shortly after I returned from my last deployment in Afghanistan. The counselor gave me some tips and topics to talk with the kids about. It actually worked out really well. The counseling with my husband was weekly for 11 weeks. My husband was in the air force in his younger years, but he had never deployed. So, there were some things about my behavior that he didn’t understand. I was upset by loud noises when I returned. I also had trouble falling asleep and staying asleep. The counseling was really helpful for both of us.
LIEUTENANT COLONEL JULIE
Julie, an air force reservist who served as a flight nurse and as a CCATT nurse in Iraq and Afghanistan, described why she went for counseling after her third deployment.
She stated:
I went for counseling shortly after I got home from my last deployment because I felt kind of numb inside. I didn’t feel up to taking over my share of the household chores, and I was having words with my husband about “the division of labor” in our family. Well, the counselor said that I had compassion burnout, a form of PTSD. It is when you have suppressed your own feelings, your own anxieties, and your own fears. It was a pretty natural thing to do because you had to take care of people, and you had to do it very well. There was no time to let your guard down, and to not be that way. Then, when you come back, all those feelings, all that internalization comes to the surface, and I think it led to depression for me. This stuff all came to the surface when I got home. You start thinking about all the stuff you experienced in Iraq, and start talking to your peers in the reserves, there are five of us that are pretty close. We are there for each other, and even though we don’t live close, they are only a phone call away.
The counseling helped me because I was kind of spiraling the wrong way. I was self-medicating with way too much alcohol and just really not doing well. It brought me back to who I was. A lot of the therapy was just talking. Realizing that what I was feeling was OK. I wasn’t a bad person for feeling this way. We tend to beat ourselves up very badly when we think we have taken too long to adjust, or we think we didn’t do enough for patients, or we let our family down. It took me about 2 months of therapy going every week to a private therapist. I wanted to do it without any antidepressant meds, and I did. I wanted to be able to think clearly. They suggested an SSRI [selective serotonin reuptake inhibitor], but I wanted to try therapy without meds at first. That’s just the way I manage things, I wouldn’t say that would work for everybody. I couldn’t continue my career as a flight nurse if I was on an SSRI. Flying personnel are very limited on what meds that are authorized to take.
LIEUTENANT COMMANDER ZOE
Zoe was a family nurse practitioner, deployed to Afghanistan in 2009 as a member of a provincial reconstruction team, which was a tri-service augmented role. She returned home in time for the 2010 Thanksgiving and Christmas holidays.
She stated:
Although I was excited about the holidays, I was also worried. It can be such a “false” time for people, being stressed, but at the same time you are supposed to enjoy things and be thankful.
I found that I felt so emotionally labile. I remember going to my daughter’s holiday performance [starts crying while talking] and seeing these beautiful, carefree children, so joyful. I remember I started crying. I remember being so glad that children in the United States could be so joyful and free. I was happy that the people there were so happy and safe. But I was so torn because I knew at that very same time people half a world away were still facing danger every day. I kept thinking of the military people who were friends of mine and the Afghans who do not even have the ability to feel so much joy and for their children. So, that was hard for me. I remember feeling thankful and feeling so much appreciation and love, but also guilt and sadness, too.
And people didn’t understand. My older daughter would look at me and say, “Mom, why are you crying?” I would do my best to explain, and my husband would just hold my hand. I don’t think people really understand unless they have gone through that type of experience, where they really realize how blessed they are [crying].
Zoe talked about feeling cheerful, but having guilt. She mentioned that Facebook was helpful in keeping in touch with some of the people with whom she was deployed. She stated:
Facebook was helpful but some would post things saying, “I am really struggling, I can’t find a job,” and I would feel a level of responsibility, like I need to continue to take care of them, like what I did when I was over there, you know, physically and mentally I took care of them, like when someone was dealing with immediate trauma or when we had a vehicle roll over. For example, one of our guys lost his hand and another is paralyzed from the waist down. They were on my team, and it was my responsibility to help them when they were going through these things.
So when people were all the way across the country and they’d post something that sounded desperate, I had no real ability to help them, and they were struggling. Some said they were struggling at the VA [Veterans Administration], you know, they wrote, “I spent 3 hours waiting at the VA, and they told me that my appointment was cancelled.” I just felt so helpless, but still so responsible. Even within this last month, a guy I was stationed with posted a link to a YouTube video about one of the navy mobilization augmentees who deployed with us and worked with our civil affairs team that was with the provincial reconstruction team. I learned that she had gone through severe depression and had attempted suicide. I just found this out a month ago, and my initial reaction was, “How did I not reach out to her? What did I miss when we were deployed? What did I not recognize? Did I not help her get connected with mental health when we got back?” I feel a level of responsibility when I learn that people from our team have struggled. I guess I’ll always have that feeling to some degree.
So, while social media and those type of connections are really helpful, it’s difficult because you wonder what your responsibility is when you read someone’s status update, and it is troubling. You see that someone is threatening in some way to harm themselves. What do you do with that information? That has happened to multiple members of our team. Basically, what I have done is write to them online to tell them to get help locally. You have to ease up on that sometimes which is hard for us as nurses because we connect with people. It’s not just intellectually, it’s a deeper connection, a holistic, caring connection. And when you read what they have written, it’s really a call for help, and you know that when you read it. What do you do with that? You can’t just scroll down through it and say that it is an obvious call for help, he’s struggling or she’s suicidal. The guilt and the responsibility have been difficult to this day. It’s been 3 years back, and people still have issues. The postings can bring me right back. I’ve noticed over time that those who seem to be struggling the most are those who were single at the time and without kids and maybe they didn’t have a home command. I know that our Guard guys have struggled a lot and some of our reservists.
LIEUTENANT COMMANDER CATHERINE
Catherine is a navy family nurse practitioner.
She recalled:
When I got home one of the most surprising things to me was how angry I was. Anger was an emotion that I felt strongly. I was glad to be home. My anger was not at all directed toward my family, or friends, or coworkers. It was undirected anger. I didn’t have a focus for it. It was just anger! Politically, I tend to be far left. The politics of war was complicated.
I certainly did not believe in why we were in Iraq. The whole country had been whitewashed in terms of thinking about these weapons of mass destruction. It was the 9/11 disconnect. Iraq wasn’t the source of the terrorists that brought down the World Trade Center and the Pentagon. I remember feeling what the country was thinking, that part I had to resolve somehow because there I was, and so the easier part was to think, there are hurt people, and they need care. And so, that just made it easy. I think for our unit, the politics of war weren’t often discussed because I think we were so focused on taking care of our patients that you didn’t have to care about the politics. Let somebody else worry about that. That part was easy to reconcile even though I could say that the politics would have been a source of anger. Except when I came home, I can’t say that I was pissed at the president, I couldn’t say that I was mad at George W. Bush. That could have been in the mix, but I can’t say that was why I was mad, maybe it was collective or cumulative. I don’t even know. I can’t even describe it. It was a surprising emotion for me. It was unexpected. I’m pretty optimistic and levelheaded, and I don’t like to be angry [laughing]. So, I don’t stay angry for very long about things [laughing]. It was kind of an overwhelming emotion.
I remember being at a restaurant, and there was this man, and he was smoking, and smoking was not allowed in the restaurant, and it was very offensive to me. I don’t like to be in public places where people are smoking. And so I remember asking the waitress to ask him to put out his cigarette. He wasn’t sitting close enough for us to talk. He carried the cigarette over to a booth that was near us, and it was almost like passive-aggressive behavior. He kept the cigarette lit for quite some time, and I’m sure that he knew that I had asked for him to put it out. I just felt like he was such an ass [laughing]. I had to really fight the urge to just verbally unload on this man. I knew, if I opened my mouth, he was going to get the full brunt of that anger. So, I really had to squelch that because I knew that I would have not been a good example.
When I came back from Afghanistan, my son at the time was the age of most of the casualties we were getting. It’s hard not to identify with that from a maternal perspective. I also think what helped me was my age, my maturity, my experience, and my stable marriage. The fact that I was a parent and my professional roles were things that have helped me. I have had a lot of friends who have had terrible PTSD to the point of incapacitation. I acknowledge my emotions, I’m OK with them. I give myself permission to feel my feelings, and I’m a talker, and I think those things have helped me process a lot of deployment experiences. And, I have great family support and understanding. Anger and rage were big things that I came back with. Again, they were not directed toward anybody.
Catherine related that coming back from her second deployment, which was to Afghanistan, she felt that she knew what to expect emotionally. She didn’t consider herself angry. She wasn’t doing combat trauma; instead she was on a provincial reconstruction team that had convoy operations every day. She stated: “The risk was very great.” She reflected that being on this team was challenging from the length of time involved to the “risk and vulnerabilities.” She added:
A lot of people do not go outside of the wire. I did 80 missions in full gear, two weapons—a 9 mm and a rifle and a full combat load of ammunition. To do that, I am riding in an armored vehicle, an MRAP [mine resistant ambush protected], and I’m carrying 60 pounds of gear.
LIEUTENANT COLONEL NATASHA
Natasha, an air force nurse, remarked:
Before I got my antidepressants, loud noises and crowds bothered me a great deal. I couldn’t handle these things, they made me very, very anxious. Once I got my medicine, I was doing great! I call it, “Better living through chemistry” [laughing]. While I was deployed, a biomedical technician committed suicide. He was one of my 17-member team and thought his problems were insurmountable and killed himself while we were there. That was tough. It may have had some effect on my depression, you never know. I think I recognized my depression fairly early and made the decision to try the medicine because of my family history. I saw my mother suffer for years with untreated depression, and I knew how bad that could get. I think I was pretty proactive.
You know how it is at times, you second guess yourself wondering if you jumped the gun with meds. But then you remind yourself how bad you felt before you started on the meds. When my mom passed away, I remember traveling cross-country for 3 days and forgetting my medicine and again witnessed that darkness again that I forgot existed. I’m pretty happy with my pills. I have an anxiety-based kind of depression, and I had panic attacks. I’m much better now.
LIEUTENANT COMMANDER JUSTIN
Justin, a navy reservist, described why he went for help after he returned from Afghanistan:
So, coming home my family didn’t know what to do with me. I didn’t want to be in crowds or around most people. My now ex-wife really couldn’t deal with any of this. A friend of mine came by with his wife, they knocked on the front door, and I ended up hiding under the kitchen table. I developed a very close relationship with another U.S. service member while I was deployed. The question when I got home was do I want to work on my marriage, or continue with a relationship with this other person. I knew that there were some serious problems with my relationship with my wife. There was a lot of “her-way-or-the-highway” kind of thing. When I came back I wanted to work on our relationship, yet it had to be on her terms. I couldn’t deal with that. I went to see a therapist because I needed to calm down. I had to get this hyper-alertness out of my system. I couldn’t spend the rest of my life in the apartment or under the kitchen table. I couldn’t ask my 18-month-old son to decide what kind of cereal to buy because I couldn’t make a decision, and I was the grown-up.
LIEUTENANT DARLA
Darla, a navy operating room (OR) nurse, explained why she sought help:
I went and saw deployment mental health when I got back because I had only been home for a few days, and things were not going well with me and my boyfriend. He had been very supportive while I was deployed, but he was kind of cold and distant when I came home. My boyfriend had complained that I was forgetful since I came home. I said, “That’s kind of me.” I am a multitasker and think about a lot of things at the same time. He disagreed. The first day I was supposed to go to work, I accidently left my keys in his truck, and he had left earlier that morning. So, I couldn’t drive my car because my keys were in his truck. I had to take a taxi to work, and later I got my keys from his truck. He was pretty impatient and annoyed about this happening. He’s pretty impatient. He was particularly impatient and easily annoyed since I came home from deployment. His fuse seemed much shorter than I remembered. He didn’t like being inconvenienced with anything. The mental health counselor listened to me and helped me problem solve. I went to see her a couple of times. I decided to leave my boyfriend.
CAPTAIN CORABETH
Corabeth grew up on a cattle ranch near Taos, New Mexico. As a young girl, she cared for the newborn calves and thought about becoming a veterinarian. In her teen years, she became more attracted to a nursing career and joined the future nurses’ club in her high school. After graduating from college, she began working on a medical–surgical unit near Santa Fe, New Mexico. After a few years, Corabeth joined the Army National Guard.
Corabeth related:
I was deployed to the Abu Ghraib prison hospital in Iraq. We closed it down and moved the detainees to Camp Cropper, Iraq. I was in Iraq for 1 year. I was there from April 2006 to April 2007. Our mission was detainee health care. I maybe saw about 5% U.S. or coalition troops, the rest were detainees or local civilians. At the time of my deployment, I was stationed at the 2nd General Medical Center in Landstuhl, Germany. The reason I volunteered for Iraq was to gain experience and better understand war injuries we were receiving in Germany. I wanted to relate better to the troops I was caring for at Landstuhl.
Four nurses from Landstuhl deployed at the same time to Abu Ghraib. When I returned from Iraq, I came back to an ambulatory care and day surgery position. It was hard to return to Landstuhl because no one knew about our mission with detainee care. Some people had difficulty relating to it. They thought that it would be better for us returning not to go back to a regular floor right away. I would say that about 6 months after deployment, the real challenges began. I don’t know if it’s because the “honeymoon phase” was over, or if that’s just when things catch up with you. After the deployment, I was still on active duty and was sent to Fort Bliss in El Paso, Texas. When I was in El Paso, I was all alone living in an apartment by myself. I was a captain in charge of all these lieutenants. I didn’t have any friends. I was totally isolated. The guy I had met while on leave became my fiancé. But he was not in El Paso. It was hard.
When I was released from active duty, I left El Paso, and I moved in with my fiancé, who is now my husband, in Albuquerque. And then I had therapy, about $7,000 worth. I’m cured and life is great now. I was still in the military reserves, and I could have waited and tried to go through the Veteran’s Administration [VA] for mental health counseling. If I went to the VA, I could have received some disability. There’s a girl I know who went through the VA and received disability for PTSD.
With 5 years of active duty, I guess I could have asked for VA benefits. Being screened and interviewed gave me a boatload of anxiety. My PTSD was totally linked to the mission of detainee care. I got myself in trouble working 60 to 72 hours a week for a year. All of us had volunteered to take care of soldiers, not detainees. Where I got myself in trouble probably goes back to my codependency and inability of establishing boundaries. What I will and will not do to take care of someone. I think all of us nurses felt “all children are God’s children” and you should treat them as such. It was challenging, and I think I tried to overcompensate for some of my colleagues. You give, give, give, give, and give. Our mission changed the hearts and minds of the Iraqi people. And at some point, you realize that all you did, did not make a big difference. And then, you feel like you were not good enough to make a difference. I had severe depression. It was one of those dumb things. I put my mind and my heart into something, and it still did not make a difference. So anyway, that’s what it was for me. It hit me while I was over there. Also, about three-quarters of the way through the deployment, my roommate shot herself. She was not a nurse, she was a medical service corps officer, who was with an ambulance company. She survived. She shot herself in the chest. I had a lot of guilt about this. She’s disabled. She had threatened to go out and shoot all the nurses. It was all over the news. Everybody cracked. I just cracked later than everyone else [laughing]. I’m proud of that. Doing detainee health care for a year was about 3 to 6 months too long.
With my experiences in Iraq and being a nurse, I feel I’m respected. Once they know I’m a veteran, people respect me for what I know, what I was able to do, and for my opinion. Working for the VA has been a warm experience. I try to see things as positive. I am grateful for the respect I get. Being in therapy for 1-1/2 years was an absolute growth experience for me. The cost was worth it. I really learned so much about human nature. I take my deployment experience, and all that I learned through therapy, and integrate it into my clinical practice as a nurse practitioner. I feel like I am an effective and compassionate practitioner. I feel like I’ve taken a negative experience and put a positive spin on it, which has benefitted me and my patients.
CAPTAIN COURTNEY
Courtney is an Air National Guard nurse.
She stated:
I felt that they were very, very good sending you to war. I felt very prepared. But, you were not prepared to come back. You are hypervigilant. I was always alone in Afghanistan, but I was never by myself if you know what I mean, if that makes any sense.
My husband took some time off, but then he had to go back to work. With me, they make you take a month off. You can’t just go back to work. So, I’d be alone in the house, and I’d hear doors closing. I was afraid to take showers. There was really bizarre stuff. I couldn’t sleep. Ambien didn’t work. That took a long time. I still have occasional problems with sleeping, but it is much better. I knew it was psycho-processing, and you just have to go through it. Loud noises were bad. I wanted to get a weapon [laughs], and I’m such a democrat! I said to my husband, “We have to go buy a weapon” and he said, “No, we don’t” [laughs]. I don’t even know where that came from except that I carried a weapon with me for 7 months, and I felt naked without it. We have a “Louisville Slugger” by our bed now. This baseball bat is my weapon, but I can’t put it in my pocket. So it does take a while to transition back. In the air force, they have mental health people that call you to check in with you after you’ve been back for a certain amount of time. Well, I never got called. It is easy to fall through the cracks when you are one-zees/two-zees in the [Air National] Guard. There were just a bunch of things that I needed to get off my chest. So, I talked to the chaplain at the base. He’s a full-bird [colonel]. I also talked to a lot of the nurses who I went to combat skills training with because I knew them all very well. We kind of, among ourselves, talked through a lot of stuff. They were all air force, and most were active duty. I was one of three Guardsmen. I don’t think there were any reservists in my group. There were doctors, nurses, shrinks, and a nurse anesthetist. It was a mix of people. We went to combat training skills together, and it was about a month long. It was classes and literally learning what to do, how to defend yourself. We lived in dorms and it was at Fort Dix, New Jersey. But, I also had classes in San Antonio, Texas. I mean they really prepared you. You knew how to break down your weapon and load it. You really learned what to do.
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